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Home
About Us
About Dr. Bragg
Providers and Staff
Testimonials
Digital Cookbook
Blog
FAQ’s
Refer a Friend
Site Terms
Programs
GLP-1 Injections
Overview / GLP-1 Weight Loss
Semaglutide Program
Tirzepatide Program
Am I a Candidate?
Classic Medical Weight Loss
Classic Program Overview
Appetite Suppressants
Hormone Optimization
Biote® Overview
Biote® East Orlando
Biote® Dr. Phillips / SW Orlando
Biote® Lake Mary
Biote Men’s Health Quiz
Biote Women’s Health Quiz
Pricing
GLP-1 & Semaglutide Pricing
Classic Weight Loss Plan Pricing
Biote Pricing
Telehealth
Our Telehealth Process
Pricing Semaglutide Injections Telehealth
Candidate for Semaglutide?
Contact
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Home
About Us
About Dr. Bragg
Providers and Staff
Testimonials
Digital Cookbook
Blog
FAQ’s
Refer a Friend
Site Terms
Programs
GLP-1 Injections
Overview / GLP-1 Weight Loss
Semaglutide Program
Tirzepatide Program
Am I a Candidate?
Classic Medical Weight Loss
Classic Program Overview
Appetite Suppressants
Hormone Optimization
Biote® Overview
Biote® East Orlando
Biote® Dr. Phillips / SW Orlando
Biote® Lake Mary
Biote Men’s Health Quiz
Biote Women’s Health Quiz
Pricing
GLP-1 & Semaglutide Pricing
Classic Weight Loss Plan Pricing
Biote Pricing
Telehealth
Our Telehealth Process
Pricing Semaglutide Injections Telehealth
Candidate for Semaglutide?
Contact
Home
About Us
About Dr. Bragg
Providers and Staff
Testimonials
Digital Cookbook
Blog
FAQ’s
Refer a Friend
Site Terms
Programs
GLP-1 Injections
Overview / GLP-1 Weight Loss
Semaglutide Program
Tirzepatide Program
Am I a Candidate?
Classic Medical Weight Loss
Classic Program Overview
Appetite Suppressants
Hormone Optimization
Biote® Overview
Biote® East Orlando
Biote® Dr. Phillips / SW Orlando
Biote® Lake Mary
Biote Men’s Health Quiz
Biote Women’s Health Quiz
Pricing
GLP-1 & Semaglutide Pricing
Classic Weight Loss Plan Pricing
Biote Pricing
Telehealth
Our Telehealth Process
Pricing Semaglutide Injections Telehealth
Candidate for Semaglutide?
Contact
IV Hydration Medical History Form
Currently Not Available
Date
Name
Phone
Email
Allergies
Current Medications
1. Have you ever had prior IV nutrient infusion?
No
Yes
If so, when
Did you have problems with prior infusions including reactions, allergies, or access issues?
2. Do you have any of the following conditions?
None
End Stage Renal Disease
Cerebral Hemorrhage
Hyperparathyroidism
Congestive Heart Failure (CHF)
Myasthenia Gravis
Hypermagnesium
Kidney/Renal Disease
Hemolytic Anemia
Current UTI
Cardiac Arrhythmia
Low Blood Pressure
Kidney Stones
Liver disease
3. Have you been told that you need to start dialysis or are you currently on dialysis?
Yes
No
4. Are you taking or have you been told you need to take Digoxin?
Yes
No
5. Have you been told you have a decreased GFR or kidney problem?
Yes
No
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